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 BRADDOM’S
REHABILITATION
CARE
A Clinical Handbook
This page intentionally left blank

     
 BRADDOM’S
REHABILITATION
CARE
A Clinical Handbook
David X. Cifu, MD
Chairman
Department of Physical Medicine and Rehabilitation
Herman J. Flax, MD Professor
Virginia Commonwealth University School of Medicine
Principal Investigator
Veterans Affairs/Department of Defense Chronic Effects of Neurotrauma Consortium
Richmond, Virginia

Henry L. Lew, MD, PhD

Tenured Professor, University of Hawaii School of Medicine
Chair, Department of Communication Sciences and Disorders
Honolulu, Hawaii
Adjunct Professor, Department of Physical Medicine and Rehabilitation
Virginia Commonwealth University School of Medicine
Richmond, Virginia
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

BRADDOM’S REHABILITATION CARE:

A CLINICAL HANDBOOK ISBN: 978-0-323-47904-2

Copyright © 2018 by Elsevier, Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopying, recording, or any information storage
and retrieval system, without permission in writing from the publisher. Details on how to
seek permission, further information about the Publisher’s permissions policies and our
­arrangements with organizations such as the Copyright Clearance Center and the Copyright
­Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by
the Publisher (other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and
experience broaden our understanding, changes in research methods, professional prac-
tices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge
in evaluating and using any information, methods, compounds, or experiments described
herein. In using such information or methods they should be mindful of their own safety
and the safety of others, including parties for whom they have a professional responsibility.
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vidual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors,
or editors, assume any liability for any injury and/or damage to persons or property as a
matter of products liability, negligence or otherwise, or from any use or operation of any
methods, products, instructions, or ideas contained in the material herein.

Library of Congress Cataloging-in-Publication Data

Names: Cifu, David X., editor. | Lew, Henry L., editor.
Title: Braddom’s rehabilitation care : a clinical handbook / [edited by]
David X. Cifu, Henry L. Lew.
Other titles: Rehabilitation care | Supplement to (expression): Braddom’s
physical medicine & rehabilitation. Fifth edition.
Description: Philadelphia, PA : Elsevier, [2018] | Includes bibliographical
references and index.
Identifiers: LCCN 2017021675 | ISBN 9780323479042 (pbk. : alk. paper)
Subjects: | MESH: Rehabilitation—methods | Handbooks
Classification: LCC RM700 | NLM WB 39 | DDC 617.03—dc23 LC record available at
https://lccn.loc.gov/2017021675

Senior Acquisition Editor: Kristine Jones

Content Development Specialist: Meghan Andress
Publishing Services Manager: Patricia Tannian
Senior Project Manager: Claire Kramer
Design Direction: Amy Buxton

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Contributors
Mohd Izmi Bin Ahmad, MBBS, MRehabMed, CIME (USA)
Rehabilitation Physician
Head, Department of Rehabilitation Medicine
Hospital Pulau Pinang
George Town, Penang, Malaysia

Eleftheria Antoniadou, MD, FEBPMR, PhDc

Consultant
Rehabilitation Clinic for Spinal Cord Injury
Patras University Hospital
University of Patras
Patras, Greece

Joseph Burris, MD
Associate Professor of Clinical Physical Medicine and Rehabilitation
University of Missouri
Columbia, Missouri

Maria Gabriella Ceravolo, MD, PhD

Professor of Physical and Rehabilitation Medicine
Department of Experimental and Clinical Medicine
Politecnica delle Marche University
Director of Neurorehabilitation Clinic
University Hospital of Ancona
Ancona, Italy

Chein-Wei Chang, MD
Professor
Department of Physical Medicine and Rehabilitation
National Taiwan University
Taipei, Taiwan

Shih-Chung Chang, MD, MS

Department of Physical Medicine and Rehabilitation
Chung Shan Medical University
Department of Physical Medicine and Rehabilitation
Chung Shan Medical University Hospital
Taichung, Taiwan

Carl Chen, MD, PhD

Director
Department of Physical Medicine and Rehabilitation
Chang Gung Memorial Hospital
Taipei, Taiwan

   v
vi Contributors

Chih-Kuang Chen, MD
Assistant Professor
Department of Physical Medicine and Rehabilitation
Chang Gung Memorial Hospital
Taoyuan, Taiwan

Shih-Ching Chen, MD, PhD

Deputy Dean and Professor
School of Medicine
College of Medicine
Taipei Medical University
Professor and Attending Physician
Department of Physical Medicine and Rehabilitation
Taipei Medical University Hospital
Taipei, Taiwan

Chen-Liang Chou, MD
Director and Clinical Professor
Department of Physical Medicine and Rehabilitation
National Yang-Ming University
Taipei Veterans General Hospital
Taipei, Taiwan

Willy Chou, MD, HRMS

General Secretary, Superintendent Office
Chief Director, Physical Medicine and Rehabilitation
Chi Mei Medical Center
Associate Professor
Recreation and Health Care Management
Chia Nan University of Pharmacy
Tainan, Taiwan

Tze Yang Chung, MBBS, MRehabMed

Senior Lecturer, Department of Rehabilitation Medicine
University of Malaya
Rehabilitation Physician
Department of Rehabilitation Medicine
University of Malaya Medical Centre
Kuala Lumpur, Malaysia

David X. Cifu, MD
Chairman
Department of Physical Medicine and Rehabilitation
Herman J. Flax, MD Professor
Virginia Commonwealth University School of Medicine
Principal Investigator
Veterans Affairs/Department of Defense Chronic Effects of Neurotrauma
Consortium
Richmond, Virginia
 Contributors vii

Andrew Malcolm Dermot Cole, MBBS (Hons), FACRM, FAFRM

Chief Medical Officer
HammondCare
Sydney, Australia
Associate Professor (Conjoint)
Faculty of Medicine
University of New South Wales
Kensington, Australia
Senior Consultant Rehabilitation Medicine
Greenwich Hospital
Greenwich, Australia

Rochelle Coleen Tan Dy, MD

Assistant Professor
Department of Physical Medicine and Rehabilitation
Baylor College of Medicine
Houston, Texas

Blessen C. Eapen, MD
Section Chief, Polytrauma Rehabilitation Center
TBI/Polytrauma Fellowship Program Director
South Texas Veterans Health Care System
Associate Professor
Department of Rehabilitation Medicine
UT Health San Antonio
San Antonio, Texas

Julia Patrick Engkasan, MBBS (Mal), MRehabMed (Mal)

Associate Professor
Department of Rehabilitation Medicine
University of Malaya
Kuala Lumpur, Malaysia

Gerard E. Francisco, MD
Department of Physical Medicine and Rehabilitation
University of Texas Health Science Center (UTHealth)
McGovern Medical School
NeuroRecovery Research Center
TIRR Memorial Hermann
Houston, Texas

Francesca Gimigliano, MD, PhD

Associate Professor of Physical and Rehabilitation Medicine
Department of Mental and Physical Health and Preventive Medicine
University of Campania “Luigi Vanvitelli”
Naples, Italy
viii Contributors

Elizabeth J. Halmai, DO
Medical Director, Section Chief
Division of Polytrauma
South Texas Veterans Health Care System
Assistant Professor
Department of Physical Medicine and Rehabilitation
University of Texas Health Science Center San Antonio
San Antonio, Texas

Nazirah Hasnan, MBBS, MRehabMed, PhD

Deputy Director (Clinical)
University of Malaya Medical Centre
Associate Professor and Rehabilitation Consultant
Department of Rehabilitation Medicine
University of Malaya
Kuala Lumpur, Malaysia

Ziad M. Hawamdeh, MD
Senior Fellowship of the European Board of Physical Medicine and
Rehabilitation
Jordanian Board of Physical Medicine and Rehabilitation
Professor of Physical Medicine and Rehabilitation
Faculty of Medicine
University of Jordan
Amman, Jordan

Joseph E. Herrera, DO, FAAPMR

Chairman and Lucy G Moses Professor
Department of Rehabilitation Medicine
Mount Sinai Health System
Icahn School of Medicine at Mount Sinai
New York, New York

Ming-Yen Hsiao, MD
Lecturer
Department of Physical Medicine and Rehabilitation
National Taiwan University Hospital
College of Medicine
National Taiwan University
Taipei, Taiwan

Lin-Fen Hsieh, MD
Professor
School of Medicine
Fu Jen Catholic University
New Taipei City, Taiwan
Director
Department of Physical Medicine and Rehabilitation
Shin Kong Wo Ho-Su Memorial Hospital
Taipei, Taiwan
 Contributors ix

Rashidah Ismail Ohnmar Htwe, MBBS, M MED Sc (Rehab Med), CMIA

Associate Professor
Rehabilitation Unit
Department of Orthopedics and Traumatology
Associate Research Fellow
Tissue Engineering Centre
Faculty of Medicine
Universiti Kebangsaan Malaysia
Consultant Rehabilitation Physician
Rehabilitation Unit
Department of Orthopedics and Traumatology
Hospital Canselor Tuanku Muhriz
Kuala Lumpur, Malaysia

Yu-Hui Huang, MD, PhD

Associate Professor
School of Medicine
Chung Shan Medical University
Director
Physical Medicine and Rehabilitation
Chung Shan Medical University Hospital
Taichung, Taiwan

Chen-Yu Hung, MD
Attending Physician
Physical Medicine and Rehabilitation
National Taiwan University Hospital, Beihu Branch
Taipei, Taiwan

Norhayati Hussein, MBBS, MRehabMed, Fellowship in Neurorehabilitation

Rehabilitation Physician
Department of Rehabilitation Medicine
Cheras Rehabilitation Hospital
Kuala Lumpur, Malaysia

Elena Milkova Ilieva, MD, PhD, Prof.

Head of Department
Physical and Rehabilitation Medicine
Medical Faculty
Medical University of Plovdiv
Head of Department
Physical and Rehabilitation Medicine
“Sv Georgi” University Hospital
Plovdiv, Bulgaria

Lydia Abdul Latif, MBBS, MRM

Professor and Consultant Rehabilitation Physician
Department of Rehabilitation Medicine
Faculty of Medicine
University of Malaya
Kuala Lumpur, Malaysia
x Contributors

Wai-Keung Lee, MD
Chief, Department of Physical Medicine and Rehabilitation
Tao Yuan General Hospital
Tao Yuan, Taiwan

Henry L. Lew, MD, PhD

Tenured Professor, University of Hawaii School of Medicine
Chair, Department of Communication Sciences and Disorders
Honolulu, Hawaii
Adjunct Professor, Department of Physical Medicine and Rehabilitation
Virginia Commonwealth University School of Medicine
Richmond, Virginia

Chia-Wei Lin, MD
Attending Physician
Department of Physical Medicine and Rehabilitation
National Taiwan University Hospital, Hsin Chu Branch
Hsin Chu, Taiwan

Ding-Hao Liu, MD
Department of Physical Medicine and Rehabilitation
Taipei Veterans General Hospital, Yuanshan Branch
Yilan, Taiwan

Mazlina Mazlan, MBBS, MRM

Associate Professor
Department of Rehabilitation Medicine
Faculty of Medicine
University of Malaya
Kuala Lumpur, Malaysia

Matthew J. McLaughlin, MD, MSB

Assistant Professor
Division of Pediatric Rehabilitation Medicine
Children’s Mercy Hospital
Kansas City, Missouri

Amaramalar Selvi Naicker, MBBS (Ind), MRehabMed (Mal)

Professor of Rehabilitation Medicine and Head of Rehabilitation Medicine Unit
Department of Orthopedics and Traumatology
Associate Research Fellow
Tissue Engineering Centre
Faculty of Medicine
Universiti Kebangsaan Malaysia
Kuala Lumpur, Malaysia
 Contributors xi

Mooyeon Oh-Park, MD, MS

Director of Geriatric Rehabilitation
Kessler Institute for Rehabilitation
Vice Chair of Education
Research Professor
Department of Physical Medicine and Rehabilitation
Rutgers New Jersey Medical School
Newark, New Jersey

Vishwa S. Raj, MD
Director of Oncology Rehabilitation
Department of Physical Medicine and Rehabilitation
Carolinas Rehabilitation
Chief of Cancer Rehabilitation
Department of Supportive Care
Levine Cancer Institute
Carolinas Healthcare System
Charlotte, North Carolina

Renald Peter Ty Ramiro, MD

Dean, College of Rehabilitative Sciences
Cebu Doctors’ University
Mandaue City, Cebu, Philippines,
Head, Physical and Rehabilitation Medicine
Cebu Doctors’ University Hospital
Cebu City, Cebu, Philippines
Head, Rehabilitation Medicine
Mactan Doctors’ Hospital
Lapu-lapu City, Cebu, Philippines

Reynaldo R. Rey-Matias, PT, MD, MSHMS

Chair, Department of Physical Medicine and Rehabilitation
St. Luke’s Medical Center and College of Medicine
Quezon City, Metro Manila, Philippines
Clinical Associate Professor
Department of Rehabilitation Medicine
University of the Philippines–College of Medicine
Manila, Philippines

Desiree L. Roge, MD
Assistant Professor
Department of Physical Medicine and Rehabilitation
Baylor College of Medicine
Assistant Professor
Department of Physical Medicine and Rehabilitation
Texas Children’s Hospital
Houston, Texas
xii Contributors

Shaw-Gang Shyu, MD
Department of Physical Medicine and Rehabilitation
National Taiwan University Hospital
Taipei, Taiwan

Clarice N. Sinn, DO, MHA

Assistant Professor
UT Southwestern Medical Center/Children’s Health
Dallas, Texas

Anwar Suhaimi, MBBS, MRehabMed (Malaya)

Rehabilitation Medicine Specialist
Department of Rehabilitation Medicine
University of Malaya Medical Centre
Senior Lecturer
Department of Rehabilitation Medicine
University of Malaya
Kuala Lumpur, Malaysia

Yi-Chian Wang, MD, MSc

Department of Physical Medicine and Rehabilitation
National Taiwan University Hospital
Taipei, Taiwan

Chueh-Hung Wu, MD
Department of Physical Medicine and Rehabilitation
National Taiwan University Hospital
Taipei City, Taiwan

Yung-Tsan Wu, MD
Attending Physician and Assistant Professor
Department of Physical Medicine and Rehabilitation
Tri-Service General Hospital and School of Medicine
National Defense Medical Center
Taipei, Taiwan

Tian-Shin Yeh, MD, MMS

Attending Physician
Department of Physical Medicine and Rehabilitation
National Taiwan University Hospital, Yun-Lin Branch
Yun-Lin, Taiwan
Graduate Institute of Clinical Medicine
National Taiwan University College of Medicine
Taipei, Taiwan
 Contributors xiii

Mauro Zampolini, MD
Chief
Department of Rehabilitation
Italian National Health Service, USL UMBRIA 2
Foligno, Perugia, Italy

Tunku Nor Taayah Tunku Zubir, MBBS

Consultant Rehabilitation Physician
Department of Rehabilitation
Gleneagles Hospital
Kuala Lumpur, Malaysia
This page intentionally left blank

     
Preface
Over the past 4 years, we have worked diligently with more than 200 authors from
across the international community to create (1) the fifth edition of the textbook
Braddom’s Physical Medicine & Rehabilitation and (2) Braddom’s Rehabilitation Care:
A Clinical Handbook. These complementary resources compile key elements of the
field of disability medicine, ranging from the basic sciences to clinical care. While
the Braddom’s textbook is the premier reference for all academicians and practitio-
ners in physical medicine and rehabilitation, this new clinical handbook represents
the first comprehensive practical guide for trainees and practitioners across all ele-
ments of health care. Any student or clinician who sees, evaluates, manages, or
refers individuals with disability should use this handbook as his or her key source
for information. Whether the patient is a young adult with an acute combat-related
musculoskeletal injury, a teen with a sports medicine injury, an elderly person with
joint or neurologic dysfunction, a child with specialized equipment needs, or a
middle-aged individual after a life-altering trauma, this text can serve as a guide
for each patient’s clinical care. In addition to practical information and clinical
pearls, this handbook also features accompanying online slides and training mate-
rials to enhance understanding, to serve as part of core educational modules, and
to expand on the key points of the text. We are indebted to the authors of Brad-
dom’s Physical Medicine & Rehabilitation for providing the comprehensive materials
from which this clinical handbook was abstracted, the more than 50 authors who
worked meticulously to develop this special edition, and the editorial support staff
at Elsevier. We are hopeful that this handbook will be used throughout the world
to support the training of health care professionals working with individuals with
disabilities and to enhance the clinical care of those individuals with disabilities. It
is a resource that we would see in any health care and training setting and used by
the full range of trainees and practitioners. We also welcome feedback from readers
and users of it to improve the quality and usability of future iterations and editions.

David X. Cifu, MD, and Henry L. Lew, MD, PhD

   xv
This page intentionally left blank

     
Foreword
There are more than 1 billion individuals with some degree of disability, physical or
mental, in the world, and there are a growing number of practicing clinicians and
trainees to assist them in achieving and maintaining their independence. However,
there has not been a single, easy-to-use clinical guide to specifically assist these
practitioners to optimize their care. This handbook brings together all the key ele-
ments of practical clinical care in physical and rehabilitation medicine found in the
fifth edition of Braddom’s Physical Medicine & Rehabilitation into a single, convenient
source. The compact size, clinical focus, and state-of-the-art online resources make
it the must-have guide. It has been designed to be invaluable at the bedside, in the
clinic, in the office, and even in the patient’s home. Written in a straightforward
style, supported by online slides, and packed with clinical pearls, this handbook
is perfect for the full range of professionals, from the beginning student to the
advanced practitioner. Created by two of the leading international educators in the
field of physical medicine and rehabilitation, Drs. David Cifu and Henry Lew, this
book was carefully compiled by more than 50 professionals in physical medicine
and rehabilitation from more than 25 countries across the globe to reflect the latest
in the field, while remaining consistent with the Braddom’s reference textbook. It is
truly the must-have resource for all trainees and clinicians who see individuals with
acute and chronic disabilities.

Jianan Li, MD, Immediate Past President, International Society of Physical

and Rehabilitation Medicine (ISPRM)
Jorge Lains, MD, President, ISPRM

   xvii
This page intentionally left blank

     
Contents
SECTION I EVALUATION

1 The Physiatric History and Physical Examination, 3

Shaw-Gang Shyu

2 History and Examination of the Pediatric Patient, 14

Chia-Wei Lin

3 Adult Neurogenic Communication and Swallowing Disorders, 18

Ming-Yen Hsiao

4 P sychological Assessment and Intervention in Rehabilitation, 24

Willy Chou

5 Practical Aspects of Impairment Rating and

Disability Determination, 28
Maria Gabriella Ceravolo

6 Employment of People with Disabilities, 34

Renald Peter Ty Ramiro

7 Quality and Outcome Measures for Medical Rehabilitation, 39

Elizabeth J. Halmai

8 Electrodiagnostic Medicine, 44
Chein-Wei Chang

SECTION II TREATMENT TECHNIQUES AND SPECIAL

EQUIPMENT

9 Rehabilitation and Prosthetic Restoration in Upper

Limb Amputation, 51
Joseph Burris

10 Lower Limb Amputation and Gait, 57

Matthew J. McLaughlin
11 Upper Limb Orthoses, 66
Chih-Kuang Chen

12 Lower Limb Orthoses, 75

Tze Yang Chung

13 Spinal Orthoses, 85
Wai-Keung Lee

   xix
xx Contents

14 Wheelchairs and Seating Systems, 92

Nazirah Hasnan

15 Therapeutic Exercise, 102

Rochelle Coleen Tan Dy

16 Manipulation, Traction, and Massage, 111

Reynaldo R. Rey-Matias

17 P hysical Agent Modalities, 119

Chueh-Hung Wu

18 Integrative Medicine in Rehabilitation, 126

Tian-Shin Yeh

19 Computer Assistive Devices and Environmental Controls, 129

Shih-Ching Chen

SECTION III COMMON CLINICAL PROBLEMS

20 B ladder Dysfunction, 137

Shih-Chung Chang

21 Neurogenic Bowel: Dysfunction and Rehabilitation, 143

Yu-Hui Huang

22 Sexual Dysfunction and Disability, 150

Tunku Nor Taayah Tunku Zubir

23 Spasticity, 157
Gerard E. Francisco

24 Chronic Wounds, 164

Julia Patrick Engkasan

25 Vascular Diseases, 173

Blessen C. Eapen

26 B urns, 178
Amaramalar Selvi Naicker

27 Acute Medical Conditions, 183

Norhayati Hussein

28 C
 hronic Medical Conditions: Pulmonary Disease, Organ
Transplantation, and Diabetes, 190
Chen-Liang Chou

29 Cancer Rehabilitation, 197

Vishwa S. Raj
 Contents xxi

30 The Geriatric Patient, 204

Mooyeon Oh-Park

31 Rheumatologic Rehabilitation, 208

Lin-Fen Hsieh

SECTION IV ISSUES IN SPECIFIC DIAGNOSES

32 Common Neck Problems, 216

Carl Chen

33 Low Back Pain, 228

Anwar Suhaimi

34 Osteoporosis, 238
Francesca Gimigliano

35 Upper Limb Pain and Dysfunction, 244

Eleftheria Antoniadou

36 Musculoskeletal Disorders of the Lower Limb, 248

Elena Milkova Ilieva

37 Chronic Pain, 257

Yung-Tsan Wu

38 Pelvic Floor Disorders, 264

Clarice N. Sinn

39 Sports Medicine and Adaptive Sports, 270

Joseph E. Herrera
40 Motor Neuron Diseases, 279
Lydia Abdul Latif

41 Rehabilitation of Patients With Neuropathies, 287

Yi-Chian Wang

42 Myopathy, 299
Ziad M. Hawamdeh

43 Traumatic Brain Injury, 305

Mazlina Mazlan

44 Stroke Syndromes, 315

Mauro Zampolini

45 D
 egenerative Movement Disorders of the Central
Nervous System, 319
Andrew Malcolm Dermot Cole
xxii Contents

46 Multiple Sclerosis, 324

Mohd Izmi Bin Ahmad

47 Cerebral Palsy, 331

Desiree L. Roge

48 Myelomeningocele and Other Spinal Dysraphisms, 338

Rashidah Ismail Ohnmar Htwe

49 Spinal Cord Injury, 345

Chen-Yu Hung

50 Auditory, Vestibular, and Visual Impairments, 355

Ding-Hao Liu
Video Contents
SECTION II TREATMENT TECHNIQUES AND SPECIAL
EQUIPMENT

16 Manipulation, Traction, and Massage

Video 16.1. M uscle Energy Technique

17 P hysical Agent Modalities

Video 17.1. Paraffin Bath

SECTION III COMMON CLINICAL PROBLEMS

25 Vascular Diseases
Video 25.1. M onophasic Ar terial Doppler Waveform

31 Rheumatologic Rehabilitation
Video 31.1. Feeding Training with Putty

SECTION IV ISSUES IN SPECIFIC DIAGNOSES

36 Musculoskeletal Disorders of the Lower Limb

Video 36.1. L achman Test

45 Degenerative Movement Disorders of the Central Nervous System

Video 45.1. C arbidopa- and Levodopa-Induced Dyskinesia

   xxiii
This page intentionally left blank

     
 BRADDOM’S
REHABILITATION
CARE
A Clinical Handbook
This page intentionally left blank

     
 SECTION 1
EVALUATION

1 The Physiatric History and Physical Examination

Shaw-Gang Shyu

2 History and Examination of the Pediatric Patient

Chia-Wei Lin

3 Adult Neurogenic Communication and Swallowing Disorders

Ming-Yen Hsiao

4 Psychological Assessment and Intervention in Rehabilitation

Willy Chou

5 Practical Aspects of Impairment Rating and Disability Determination

Maria Gabriella Ceravolo

6 Employment of People with Disabilities

Renald Peter Ty Ramiro

7 Quality and Outcome Measures for Medical Rehabilitation

Elizabeth J. Halmai

8 Electrodiagnostic Medicine
Chein-Wei Chang

   1
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 Letter-Forms.
INTRODUCTION.
In writing letters, or in preparing anything for the press, care
should be taken to write a plain, readable hand. Many a valuable
position has been lost because of poor penmanship, and many
worthy productions have been thrown into the waste-basket,
because they have been poorly written. Men of distinction can afford
to write a poor hand, to the inconvenience of friends, and the trouble
of printers, but, as a general rule, a poor writer labors under a great
disadvantage.
The following facts should be remembered in writing letters:—
1. A letter should not be written on half a sheet of paper, unless it
is a business letter.
 2. Business letters should be as brief as clearness will permit.
3. It is never allowable to write across a written page.
4. All unnecessary flourishes should be avoided.
5. Black ink is preferable, and it is more durable than any other.

THE ADDRESS.
INTRODUCTORY REMARK.

The most important part of letter-writing is to properly direct a

letter. During the past year, nearly 4,000,000 letters found their way
to the Dead Letter Office, 67,000 of which were misdirected. When
we consider the loss to business firms in not promptly receiving
important letters, the anxiety to friends and relatives in the delay of
expected letters, the expense to the government in sending them to
the Dead Letter Office, and in handling and returning them to the
writers, the proper direction of a letter becomes a matter of very
serious importance.

Definition.—The address consists of the title and name of the

person to whom the letter is written, the city and the state in which
he lives; as,—
Mr. William K. Bixby,
Houston,
Texas.

remarks.
1. Care should be taken to write the address in a clear, bold hand.
2. The usual titles are Mr., Mrs., Miss, and Master. The last title is used in
addressing a boy.
3. Esq. is sometimes placed after the name, instead of placing Mr. before. It is
used more especially with the names of lawyers, artists, and men of social
position. When Esq. is used, never use Mr.
 Position.—The title and name should be written about the middle
of the envelope, beginning on the left. Below the title and name, and
farther to the right, should be written the city; below the city, the
state.

remarks.
1. It is customary to abbreviate the name of the state. Great care, however,
should be taken to properly abbreviate the word. Some abbreviations are so
similar to each other that mistakes frequently arise:
2. The address should never be written diagonally.

Punctuation.—A comma should be placed after the name of the

person, and after the name of the city. A period should be placed at
the end.

remarks.
1. Mr., Mrs., Esq., Rev., Dr., Prof., Pres., Capt., &c., are all abbreviations, and
consequently the abbreviations should be indicated by a period. Miss is not an
abbreviation, and thus requires no mark after it. Messrs. is also an abbreviation. It
is used in addressing a firm, but it is frequently omitted.
2. If any part of a person’s name is abbreviated, a period should always be used
to indicate the abbreviation; as, John S. C. Abbott. The S. and C. without a period
really mean nothing.
3. Some place a comma between the parts of a person’s name. This, of course,
is incorrect. See p. 16 d.
4. All the words in the address should be capitalized, except prepositions and
articles.

Honorary Titles.—It is customary to give the professional title or

titles of the person to whom a letter is directed, and if he occupies
some responsible position, this also should be indicated in the
address; as,—
Rev. E. O. Haven, D.D., LL.D.,
Chancellor of Syracuse University,
 Syracuse,
N. Y.

remarks.
1. Honorary titles should be given for two reasons:—
(a) As a mark of respect.
(b) The address will be more readily recognized by postmasters, and the
letter will be more likely to reach its destination without delay.
2. When titles are written after a person’s name, a comma should be placed
after each title, for the reason that a comma would be necessary, if the title was
written out in full; as, A. M., D.D., LL.D.
3. Some writers make the mistake of placing a period after the first L in LL.D.
This title stands for Doctor of Laws, the LL. indicating the plural of Law. As the two
letters stand for one word, the period must necessarily be placed after the second
L.
4. Hon. applies to judges, senators, representatives, heads of government
departments, mayors, and others of similar rank; as, Hon. Thomas M. Cooley.
5. His Excellency applies to the President of the United States, an Ambassador
of the United States, or the Governor of a State. This title should be written on a
line by itself; as,—
His Excellency,
Gov. C. M. Croswell,
Adrian,
Mich.
6. In addressing a married lady, the professional title of her husband is
sometimes used; as, Mrs. Dr. Haven.
7. Two professional titles meaning the same thing should never be used; as, Dr.
A. D. Smith, M. D.

Large Cities.—When the person to whom the letter is addressed,

lives in a large city where letters are delivered at places of business
or private residences, the title and name, number of house and
street, the city, and state should be given; as,—
A. S. Barnes & Co.,
34 and 36 Madison St.,
 Chicago.
Ill.

remarks.
1. The title and name should be written first, the number and street to the right
and a little below, the city below the name of the street, and the state under the
city.
2. The name of the state might be omitted in the address above given. It is not
really necessary to give the state, when the city is so widely known that no mistake
can arise, if the name of the state is omitted; as, New York, Philadelphia, Boston.

Small Towns and Villages.—The name of the county in which a

small town or village is located, should always be given in the
address. If the person to whom the letter is written, lives in the
country, the nearest post-office must be given, together with the
county and state. The name of the place in which a person lives, and
his post-office address, may be two very different things.
Mr. George Harvey,
Palmyra,
Lenawee Co.,
Mich.

remarks.
1. The title and name should be written first; the town, village, or post-office,
second; the county, third; the state last.
2. Sometimes letters are detained at post-offices, by reason of the directions not
being sufficiently complete.

Addressed Envelopes.—It is the custom with business firms, when

an answer to a letter is asked as a favor, to send, within the letter, a
stamped envelope properly addressed. The address is usually
printed, so that no mistake can be made. In all cases, even when an
addressed envelope is not required, when a favor is asked from an
acquaintance or a friend, and an answer is desired, a postage stamp
should always be inclosed. It is certainly an unpardonable
presumption to ask even a friend to write a letter for a particular
purpose, and expect him to pay for its proper delivery.

Letters with Special Request.—Sometimes directions are written

or printed on envelopes as to the disposal of letters, if not called for
within a certain time. This should always be done when addressing
business letters. These directions are written or printed on the left of
the envelope, near the top. See form on p. 81.

The Stamp.—The stamp should be placed in the right-hand corner

of the envelope, near the top. It seems hardly necessary to say that
every letter should be properly stamped, and yet between three and
four hundred thousand letters are annually sent to the Dead Letter
Office, because the writers had forgotten to properly stamp them.

FORMS OF ADDRESS.
A letter of Introduction should be left unsealed.
 When a letter is intrusted to an acquaintance or to a friend for
delivery, it should not be sealed.

LETTER-FORMS.
I. Adrian, Mich., Nov. 6, 1877.
II. Mr. William K. Bixby,
Houston, Texas.
III. Dear Sir,—
IV. Your favor * * * * * *
* * * *
V. Very truly,
Joseph M. Blain.
In the letter-form above given, there are five parts to be
considered:—

I. The Heading.
II. The Address.
III. Introductory Words.
IV. The Body of the Letter.
 V. The Conclusion.

I. THE HEADING.

Definition.—The heading consists of the name of the city in which

the writer lives, the state, the month, the day of the month, and the
year; as,—
Adrian, Mich., Nov. 6, 1877.

remarks.
1. Great care should always be taken to give in the heading, not only the city,
but also the state. If the letter should be sent to the Dead Letter Office, the heading
will properly indicate the place to which the letter is to be returned.
2. The heading indicates to the person who receives the letter where an answer
is to be sent.
3. Sometimes the day of the week is given; as, Adrian, Monday, Nov. 5, 1877.

Punctuation.—A comma should be placed after the city, state, and

date. A period should be placed at the end. If a word is abbreviated,
a period should be used to indicate the abbreviation, and a comma
should also be used, if the word written out in full would require a
comma; as,—

Adrian, Michigan, November 6, 1877.

Adrian, Mich., Nov. 6, 1877.

remarks.
1. Some writers thoughtlessly place a comma between the name of the month
and the day of the month; as, November, 6, or Nov., 6. The 6 forms an essential
part of the month, and should not be separated from it by a punctuation mark.
2. It is better to omit st, th, or d after the number indicating the day of the month.
It certainly looks neater to write the date without the marks and dots that
sometimes disfigure the heading of letters.
3. Some prefer to place the number before the name of the month; as, Adrian,
Mich., 6 Nov., 1877. This, however, is not the usual practice.
 Large Cities.—In large cities where letters are delivered by letter-
carriers, it is necessary to give, in the heading of a letter, the number
of the house and the name of the street. The order should be
number, street, city, state, month, day of the month, year; as,—
215 Prospect St., Cleveland, Ohio,
March 5, 1877.

remarks.
1. Sometimes the size of the paper necessitates the use of three lines for the
heading. If this should be necessary, the number of the house and the name of the
street should be on the first line; the city and state, on the second; the month, the
day of the month, and year, on the third. Each line should commence farther to the
right than the preceding; as,—
215 Prospect St.,
Cleveland, Ohio,
March 5, 1877.
2. As few lines as possible should be used in the heading. In sending letters
from well known cities like New York, Philadelphia, &c., it is not necessary to give
the state. When the name of the state is omitted, the heading can usually be
written on two lines.
3. A period should be placed after St., because it is an abbreviation. A comma
should also follow the period, because the word written in full would require a
comma. 215 Prospect St., is one item; Cleveland, a second; Ohio, a third; March
5, a fourth; 1877, a fifth.

A Small Town or Village.—If the place in which the writer lives, is a

small town or village, the name of the place, county, and state should
be given; as,—
Palmyra, Lenawee Co., Mich.,
Sept. 13, 1877.

remarks.
1. The county should be given so that an answer to the letter may be properly
directed.
2. If the writer lives in the country, the post-office where his letters are received,
should be given, and not the place where he lives.
 Hotels.—When a letter is written at some prominent hotel, it is
customary to give the name of the hotel in the heading; as,—
Grand Central Hotel, New York,
Jan. 10, 1877.

Seminaries and Colleges.—In writing from a seminary, college, or

university, the name of the institution is sometimes given; as,—
Female Seminary, Cleveland, Ohio,
April 11, 1877.

Position.—The heading should be written on the first line, on the

right hand, commencing about the middle of the line. If more than
one line is required, the second line should commence farther to the
right than the first, and the third than the second.

remarks.
1. When a letter does not fill a full page, the heading should not be written on the
first line. The space at the head of the letter should be about the same as at the
bottom. In business letters, this is not necessary.
2. Some write the city, state, month, &c., at the close of a letter. This is not
however, the usual form.

II. THE ADDRESS.

Definition.—The address in the inside of a letter should be the

same as the address on the envelope. It consists of the title and
name of the person to whom the letter is written, and the place of his
residence; as,—
Mr. William K. Bixby,
Houston, Texas.

remarks.
There are several reasons why the address should be written within the letter:—
 1. Business men usually take an impression or make a copy of all letters written
by themselves or their agents. It is a great convenience to have the address within
the letter, so that it can be referred to, if necessary, at any time.
2. If the envelope is accidentally torn off, or is lost by not being properly sealed,
the letter can still be forwarded to its destination, if the address is written within.
3. It is frequently the habit, on receiving a letter, to destroy the envelope.
Sometimes, after the envelope is destroyed, the letter is lost. If there is an inside
address, the letter, if found, can be returned.

Punctuation.—A comma should be placed after the name of the

person and of the city. A period should be placed at the end.

remarks.
1. By placing to before the address, it will be seen that a period is required at its
close, just as a period is required at the end of the address on the envelope; as, To
William K. Bixby, Houston, Texas.
2. Some writers place a colon after the name of the state, but the practice is not
a correct one. A semicolon should never be used.

Large Cities. When the person to whom the letter is written, lives
in a large city, the number and name of the street should be given,
as on the outside address; as,—
A. S. Barnes & Co.,
34 and 36 Madison St., Chicago.

remark.
If three lines are necessary, the title and name should be on the first line, the
number and street on the second, the city and state on the third.

Small Towns and Villages.—When the letter is addressed to a

small town or village, the county in which the town or village is
situated, should be given; as,—
Mr. George Harvey,
Palmyra, Lenawee Co., Mich.
 remark.
The title and name should be on one line; the town or village, county, and state
should be on the second.

Letters to Intimate Friends or Relatives.—In writing letters to

intimate friends or relatives, the address should be written at the
close of the letter, at the left, commencing on the line immediately
following the signature. It would be too formal to write the address at
the head of the letter, and it would not be in keeping with the
introductory words which immediately follow; as,—
Milburn Wagon Works, Toledo, Ohio,
Nov. 2, 1877.
Dear Mother,—
Your letter * * * * * *
* * * * * *
Very affectionately,
Edgar W. Curtis.
Mrs. James E. Curtis,
Adrian, Mich.

remark.
When the heading occupies only one line, it is better to leave a blank line
between the heading and the address.

Position.—The address should commence on the left, and should

be written on, at least, two lines. The title and name should be on
one line; the city and state, on the second, and farther to the right.
The address, if possible, should be written on two lines. If the
heading consists of two or three lines, the address should
commence on the line immediately following the heading. If the
heading consists of one line only, a blank line should be left between
the heading and the address.
 III. INTRODUCTORY WORDS.

Definition.—The introductory words consist of the greeting or

salutation; as,—
Dear Sir,—

remarks.
1. Sometimes only one word is used in the greeting; as, Sir, Gentlemen.
2. When Sir, Gentlemen, Friend, Father, &c., are used as introductory words,
they should always commence with a capital, as a mark of respect. In greeting
friends or relatives, do not belittle them with small letters.
3. When dear, respected, honored, and words of a like character, are not the first
words of the salutation, they should commence with a small letter; as, My dear Sir,
My respected Friend. If they commence the salutation, capitals should be used;
as, Dear Father, Respected Friend.

Punctuation.—A comma should be placed after the salutation, and

a dash may also be used. The use of the dash, however, is simply a
matter of taste.

remarks.
1. A colon should not be placed after the greeting, except in official or very
formal salutations. See p. 100.
2. A semicolon should never be used.

Position.—The introductory words may be written in three different

positions:—
1. When the address occupies two lines, the salutation should be
written on the line immediately following, commencing a little to the
right of the second line of the address; as,
Mr. Harry B. Hutchins,
Mt. Clemens, Mich.
Dear Sir,—
 2. If the address consists of three lines, the first word of the
salutation commences on a line with the number of the street; as,—
A. S. Barnes & Co.,
34 and 36 Madison St.,
Chicago.
Gentlemen,—
3. If the address is written at the close of the letter, the introductory
words should commence on a line with the body of the letter, that is,
with the marginal line; as,—
Dear Manning,—
Rest you merry in your own opinion. Opinion is a
species of property; and though I am always desirous to share with
my friend to a certain extent, I shall ever like to keep some tenets,
and some property, properly my own. * * * * *
Your well-wisher and friend,
C. Lamb.

Forms of Salutation.—Custom authorizes the use of several forms

of salutation. These may be arranged under four heads:—
1. To Strangers.
Sir, Madame, Miss ⸺.
2. To Acquaintances.
Dear Sir, Dear Madame, Dear Miss ⸺.
My dear Sir, My dear Madame, My dear Miss ⸺, imply a
better acquaintance than Dear Sir, &c.
3. To Friends or Relatives.
Dear Friend, My dear Father, Dear Henry, &c.
4. To Business Firms or Corporate Bodies.
Sirs, Gentlemen, Ladies.
 Salutations to Young Ladies.—Owing to the fact that we have no
word corresponding to Sir that can be used in addressing young
ladies, there is sometimes an uncertainty as to the proper salutation
to be used. Although Madame may refer to a married or an
unmarried lady, it is not an appropriate word with which to address a
young lady. There are three forms that may be used:—

1. To a Stranger.
Decatur, Ill., May 6, 1877.
Miss Delia L. Corbus,—
* * * * *
Respectfully,
William C. Johns.
Miss Delia L. Corbus,
Adrian, Mich.
The name is given as the salutation, and the full address is given
at the close of the letter.

2. To an Acquaintance.
Adrian, Mich., Sept. 3, 1877.
Dear Miss Dewey,—
* * * * * *
Very truly,
Thomas M. Hunter.
Miss Ella Dewey,
Hotel Madison, Toledo, Ohio.

3. To an Intimate Friend.—In writing to intimate friends, the

character of the letter, and the intimacy of the writers, will suggest
the proper forms.